Summary Patients who have senile depression with somatization symptoms are commonly encountered in clinical practice. The present case reports on a patient with senile depression who was repeatedly hospitalized and had somatic symptoms. Although the patient recovered after the first hospitalization, she suffered from a relapse one year later. As we followed up, due to the neurological findings and the response to treatment, we found that the patient is in line with the diagnoistic criteria for multiple system atrophy (MSA). The process of diagnosis and treatment of this case reminds us that clinicians need to consider differential diagnosis for refractory senile depression, especially in those patients with prominent somatization. In this case, rapid eye movement sleep behavior disorder (RBD) serves as a characteristic feature of the organic mental disorder.